MEDICARE: MICHELLE MARIE WILSON OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056012888	IL

General Provider Information

NPI Number	:	1639733371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE MARIE WILSON OTR/L

Provider Business Mailing Address
First Line	:	540 N STATE ST APT 2605
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-7236
Country	:	US
Telephone Number	:	630-418-2282
Fax Number	:

Provider Business Practice Location Address
First Line	:	540 N STATE ST APT 2605
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-7236
Country	:	US
Telephone Number	:	630-418-2282
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2019
Last Update Date	:	04/29/2019

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